Long-term results of cruciate-retaining total knee replacement in patients with rheumatoid arthritis: a minimum 15-year review

Background

There is controversy about whether to retain or excise the posterior cruciate ligament in rheumatoid knees because attenuation of the ligament is often present in this subgroup of patients. We reviewed more than 15 years of results of cruciate-retaining total knee replacements (TKRs) in patients with rheumatoid arthritis.

Methods

We reviewed patients’ charts and radiographs to evaluate knee range of motion and flexion contractures, component loosening and osteolysis at the bone–cement interface. Our primary outcome was revision of a femoral or tibial component for any reason, and the secondary outcome was revision for any reason and periprosthetic fracture during the follow-up period.

Results

Our study included 112 patients (7 men, 105 women, 176 knees). Their mean age was 49.3 (range 33–64) years. Twenty-one patients died and 16 were lost to follow-up, leaving 75 patients (119 knees) with a minimum follow-up of 15 (mean 16.1) years for our analysis. Of these, 61 patients (101 knees) were available for clinical and radiological evaluation at the final follow-up assessment. At a mean of 12.2 (range 6–16) years, revision was necessary in 14 patients (19 knees), including 1 patient with an infection. Eleven patients (11 knees) had periprosthetic fractures at a mean of 11.4 (range 5–14) years after the index operation. The survival rate, with the end point being revision of the femoral or tibial component for any reason, was 98.7% at 10 years and 83.6% at 17 years. The survival rate of revision and periprosthetic fracture was 97.6% at 10 years and 76.9% at 17 years.

Conclusion

Special attention should be paid to component loosening or periprosthetic fracture after more than 10 years of follow-up in this subgroup of patients.     

Total elbow replacement with the Souter-Strathclyde prosthesis in rheumatoid arthritis. Long-term follow-up

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.     

Cementless total hip arthroplasty for patients with rheumatoid arthritis: a more than 10-year follow-up

Background/purpose

In this study, cementless THA was performed for RA patients, and its clinical outcomes, as well as radiographic findings and implant survival rates, were examined more than 10 years after surgery in comparison with the outcomes of the same procedure performed for patients with hip osteoarthritis (OA) during the same period.

Method

We studied 28 cases of THA for RA clinically and radiologically at a minimum follow-up duration of 10 years. The patients consisted of 4 males and 22 females, with a mean age at the time of surgery of 53.1. The clinical and radiographic results were compared with an age-matched and sex-matched group of patients who had undergone THA for the diagnosis of primary or secondary OA.

Results

In the RA group, the mean Harris hip score was 48.3 before surgery, and improved to 76.8 at the time of the final survey. In the control group, the score also improved from 46.8 before to 86.5 after surgery, while revealing significant differences between the groups (p = 0.0002). In the RA group, 2 joints required revision THA on the acetabular side due to aseptic loosening, while such revision was not performed on the femoral side despite the presence of more than 2 mm of subsidence in 2 joints. The implant survival rate was 92.9 and 100 % in the RA and control groups, respectively, without significant differences (p = 0.493).

Conclusions

Although its clinical outcomes were significantly different from those for OA, a satisfactory implant survival rate was achieved, at 92.9 % in RA patients.

     

Short- and medium-term results of the thrust plate prosthesis in patients with polyarthritis

The thrust plate prosthesis is an implant with metaphyseal fixation to the proximal femur, which leaves the diaphyseal bone untouched. Therefore, this implant is preferred in younger patients. It is dependent on good bone quality in the proximal femur. Because the bone quality is reduced in patients with polyarthritis, this kind of endoprosthesis may have a higher failure rate than conventional stemmed endoprostheses in these patients. Therefore, in patients with polyarthritis, even short- and medium-term results of the thrust plate prosthesis should be analyzed. In all, 47 thrust plate prostheses were implanted in 42 patients with polyarthritis (29 with rheumatoid arthritis, 6 with juvenile chronic arthritis, and 7 with spondylarthritis) and followed prospectively. The average age at operation was 40.8 ± 10.7 years. Each patient was clinically and radiologically examined preoperatively, 3 and 6 months after the operation, and at the end of each postoperative year. The mean follow-up was 26.1 ± 10.7 months. The clinical findings were evaluated using the Harris hip score. Radiologically, 8 different zones of the thrust plate prosthesis were analyzed for radiolucencies. During the 1st year, the Harris hip score rose continuously from the preoperative average of 42.4 ± 6.5 points to 78.8 ± 10.3 points 3 months postoperatively, 82.3 ± 9.8 points 6 months postoperatively, and 86.8 ± 10.1 points 1 year after the operation. The subsequent examinations showed Harris hip score remained at the same level. Five patients (5 joints, 10.6%) had to undergo a revision of the thrust plate prosthesis due to aseptic loosening in 3 and septic loosening in 2. Six prostheses (12.6%) showed radiolucencies, mostly below the thrust plate in zones 1 and 2. Two of them were certainly radiologically loose, which raised the failure rate to 7 of 47 (14.8%). The thrust plate prosthesis improves function and alleviates pain in patients with polyarthritis to a satisfactory degree. Concerning the failure rate, this type seems to yield slightly worse results than cementless stemmed endoprostheses in the same patient group. Due to the preservation of the diaphyseal bone of the femur and the possibility of an unproblematic change to a stemmed endoprosthesis, the thrust plate prosthesis can be recommended for younger patients with polyarthritis. Received: 29 April 1999     

Early results with the thrust plate prosthesis in young patients with osteoarthritis of the hip

The purpose of this study was to evaluate the results of the Thrust Plate Prosthesis as a treatment option for osteoarthritis of the hip in young patients. Of the fifty patients (63 hips) reviewed, 31 (62%) were males and 19 (38%) females. Pre-operative diagnosis included primary osteoarthritis (23), developmental dysplasia (8), avascular necrosis (7), Perthes (4), post-traumatic arthritis (3), rheumatoid arthritis (2), ankylosing spondylitis (1), psoriatic arthropathy (1) and slipped upper femoral epiphysis (1). All components were implanted uncemented with metal-on-metal articulation. The average follow-up was 4.04 years (range 12 months-8.5 years). The mean age of the patients was 42.3 years (range 21-57 years). The mean pre-operative Harris Hip Score was 41.9 (range 12-89) and at final follow-up 89.91 (range 41-100). In 25 hips with > or = 5 yr follow-up, the average HHS at final follow-up was 84.5 (range 50-100). Complications included dislocation (2), transient sciatic nerve palsy (1), discomfort from lateral strap (2), implantation of wrong femoral head (1), revision (3 = 4.76%) and implant loosening (4) (6.35%). The thrust plate prosthesis is a useful alternative in young patients with hip arthritis and the results are comparable with other uncemented hip replacements. The added advantage is preservation of the proximal femoral bone stock, which can prove useful in future revisions.     

The GSB III elbow prosthesis in rheumatoid arthritis: a 2- to 9-year follow-up

BACKGROUND: The optimal design of an elbow prosthesis for badly damaged elbows is unkown. We evaluated 23 GSB III semi-constrained (sloppy-hinged) total elbow arthroplasties in 16 consecutive patients with rheumatoid arthritis. PATIENTS AND METHODS: After a mean follow-up period of 5 (2-9) years, we assessed quality of the cementing technique, signs of aseptic loosening, patient satisfaction, range of movement, and determined the Hospital for Special Surgery (HSS) elbow score. 3 patients had died before follow-up; thus, 20 replacements in 16 patients were available for clinical and radiographic study. All patients had endstage rheumatoid arthritis (RA) of the elbow joint. RESULTS: In 2 patients, humeral components were revised due to malorientation. 1 arthroplasty was revised due to aseptic loosening of the humeral component. There were 4 cases of intraoperative fracture which healed uneventfully. The total rate of complications was thus one-third. In 17 of 40 components, the cementing technique was rated as marginal or inadequate. We found no association between cementing technique and loosening. The arc of extension/flexion increased by 19 degrees (0-80), and the range of pronation/supination increased by 31 degrees (0-130). There were no cases of infection or ulnar nerve dysfunction. At the latest follow-up, the HSS elbow score was 84 (40-100) points. 11 of 20 elbows were rated as excellent, 4 elbows were rated as good, 2 elbows were rated as fair, and 3 elbows were rated as poor. 14 of 16 patients were satisfied with the result and the 2 patients who were not satisfied had persistent pain. INTERPRETATION: Despite the inherent problems of cementing in small-calibre medullary cavities, the clinical outcome of the GSB III arthroplasty was encouraging for patients with-end stage RA. The rate of overall complications compared favorably with other studies of semiconstrained elbow arthroplasty for end-stage RA. Most complications of the series were minor and did not necessitate revision.     

Midterm results of "thrust plate" prosthesis

The aim of this investigation was to analyze the midterm results obtained with the metaphyseal fixation principle of the thrust plate prosthesis (TPP). Survival of 214 implants in 204 patients was analyzed. Clinical (Harris hip score) and radiologic examinations were carried out on 157 of 190 TPP with a postimplantation follow-up period of at least 5 years. Failure rate was 7.0% (9 aseptic and 6 septic loosening). Harris hip score increased from 36.9 +/- 13.5 points preoperatively to 91.2 +/- 13.1 points at follow-up. Eleven TPPs showed radiolucent lines not indicating prosthetic loosening. Thrust plate prosthesis is not an alternative to stemmed endoprostheses. It may be rarely indicated in very young patients where, because of their age, several revision operations can be expected.     

Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

Proximal row carpectomy: a minimum 10-year follow-up study

PURPOSE: To assess the long-term clinical and radiographic results after a proximal row carpectomy (PRC). METHODS: Twenty patients with various degenerative and posttraumatic disorders of the wrist were evaluated. The evaluation consisted of a physical examination, plain radiographs, and completion of a questionnaire that assessed patient satisfaction, return to work status, occupational and recreational activities and restrictions, and pain level. RESULTS: Two patients (10%) had persistent pain after a PRC requiring a radiocapitate arthrodesis. The remaining 18 patients were evaluated at an average follow-up of 13.1 years (range, 10.0-17.2 y). The average wrist range of motion was 63% and the average maximal grip strength was 83% of the opposite extremity, respectively. Seventeen patients were satisfied with their outcome. One patient complained of persistent pain and was not satisfied but did not want further surgery. All but 2 patients returned to their original occupation and activity level including all 5 patients involved in workers' compensation. Follow-up radiographs showed flattening of the proximal capitate in 6 patients. Radiocapitate arthrosis was absent/minimal in 13 patients and moderate/severe in 4 patients. The presence of radiographic changes did not correlate with patient satisfaction or degree of wrist pain. CONCLUSIONS: Proximal row carpectomy is a dependable and durable procedure that results in satisfactory pain relief in the majority of patients, maintenance of functional wrist motion and grip strength, high patient satisfaction, and ability to return to work. Progressive symptomatic deterioration of the radiocapitate articulation was not observed.     

Clinical and radiological mid-term results of the thrust plate prosthesis

The purpose of this study was to perform an objective clinical and radiological assessment of the thrust plate prosthesis (TPP). Fifty-three prostheses were evaluated clinically using the Harris hip score (HHS), visual analog scale (VAS), and radiographically before surgery, at the time of discharge, and postoperatively after on average of 8.09 (range 4.61–9.93) years. The average HHS significantly (p ≤ 0.05) improved from 48 (range 18–77) points to 95 (range 46–100) points. The VAS revealed significant (p ≤ 0.05) reduction of pain at rest and under load. Radiographic analysis showed a considerable potential for osteolysis under the thrust plate. Sixteen prostheses revealed signs of radiolucent zones. In general, there was a good clinical outcome with no major limitations in function. Radiographic changes under the thrust plate indicate an adaptation processes resulting from changed biomechanics. This study suggests that the TPP could be a good alternative in total hip replacement in younger patients.     

15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis

In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was 51.6 +/- 8.9 years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was 99 degrees +/- 24 degrees (10 degrees -140 degrees ). At the tibial or femoral bone-cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome.     

Total hip arthroplasty in young patients using the thrust plate prosthesis: clinical and radiological results

Introduction The standard treatment for patients who require total hip replacement is the implantation of an intramedullary diaphyseal anchored hip prosthesis. A bone-sparing thrust plate hip prosthesis (TPP) can be used as an alternative device for young patients. The TPP relies on proximal femoral metaphyseal fixation. The theoretical advantage of leaving diaphyseal bone intact is easier conversion to a stemmed prosthesis. This retrospective study evaluated the medium- and short-term results after total joint replacement using the third generation TPP.Materials and methods Between 1997 and 2001, 58 TPPs were used for 52 patients. Clinical and demographic data were obtained from the patients charts and our electronic database. Their average age at time of surgery was 40.9±11.4 years. At follow-up, the Harris hip score, residual pain, required pain medication, and the ability to lie on the operated side were documented. Radiographic evaluation included standardized radiographs of the hip joint and the pelvis.Results Four patients required revision surgery (6.9%). For 51 of the remaining 54 TPPs, a postoperative functional and radiological status was obtained. The average follow-up was 26±11.0 months. 88% of the patients experienced some or complete relief of pain. The median Harris hip score at follow-up was 73±20.5 points. A postoperative hip dislocation occurred in 5 patients (8.6%).Conclusion Since many patients experienced some or complete relief of pain, the TPP can be recommended as a feasible implant for the treatment of hip disorders requiring total hip arthroplasty in young patients. Revision surgeries are facilitated by the good bone stock remaining in the proximal femur.     

Long-term results after omental patch repair in patients with perforated duodenal ulcers: a 5- to 10-year follow-up study

Ninety-two patients with perforated duodenal ulcers were treated at two hospitals in St. John's. Five patients were managed conservatively, and the remainder received omental patch closure. All were prescribed histamine receptor antagonists. No patient had a definitive ulcer operation. Seventy-five patients were followed up for 5 to 10 years. Fourteen patients who had been taking ulcerogenic medications had a low recurrence rate (7%); the other 61 patients who had not been taking ulcerogenic medications had a high recurrence rate (77%). Use of an omental patch is effective treatment for perforated duodenal ulcers and provides long-term benefit for patients whose perforations are associated with ulcerogenic medications. Selected patients who have not been taking ulcerogenic medication are better treated by definitive ulcer surgery at the time of perforation.     

腹腔镜前列腺癌根治术5年随访结果——中国单中心170例报道

目的探讨腹腔镜前列腺癌根治术(LRP)治疗局限性前列腺癌的中远期疗效。方法2000年10月至2005年2月由中山大学附属第三医院泌尿外科同一手术医师对连续170例局限性前列腺癌患者实施LRP。术后血清PSA水平连续2次≥0.2ng/ml定义为生化复发。控尿标准为站立或行走无尿液流出,或全天使用尿垫不超过1块。结果170例手术均获成功。手术时间平均240min,术中出血量平均100ml,拔尿管时间平均13d。主要并发症有:术中大出血1例,直肠损伤3例,输尿管损伤2例。术后切缘阳性率为24.1%,与病理分期和分级显著相关(P0.001,P0.001)。170例患者均获随访,随访时间60～112个月,平均71个月。5年无生化复发率为79.4%;在pT2,pT3a和pT3b期病例中,5年无生化复发率分别为84.9%,62.1%和76.9%。术后5年无生化复发率与切缘阳性率、病理分期、Gleason评分及术前PSA水平进行分层分析,差异均有显著性意义(P0.05)。拔尿管后129例(75.9%)控尿满意,术后1年163例(95.9%)控尿满意,5年后所有病例控尿满意。结论本研究报道国内随访时间最长的一组前列腺癌患者LRP术后情况表明,采用LRP治疗局限性前列腺癌安全可行,疗效满意。